Tuesday, January 17, 2017

UK Shuts Down Independent Midwives

A new low for harmful over-regulation: The UK has just regulated independent midwives out of business (at least for the time being).  The Nursing and Midwifery Council decided that they did not consider the indemnity cover of Independent Midwives UK (which has worked fine since indemnity cover was legally mandated in 2014) to be "adequate" after all.  So, as of 11 January last week, independent midwives have been legally barred from attending the births of their clients, severely disrupting the birth plans of these expectant parents (threatening their right to a home birth, disrupting their continuity of care, and generally undermining patient autonomy and the values that led these expectant parents to invest in an independent midwife in the first place).

The NMC's behaviour here is appalling in so many respects.  The immediate implementation of the decision makes it especially damaging. Expectant parents have formed birth plans which depend upon the independent midwives with whom they have built up relationships of trust.  To disrupt these plans without extremely good reason is deeply intrusive and unethical. As Birthrights explains in their critical open letter, NMC's actions "appear designed to cause maximum disruption and damage to independent midwives and the women they care for."  They continue:

The NMC has a key role to play in protecting public safety, yet this decision directly jeopardises the health and safety of the women it is supposed to safeguard. Beyond the very real physical health implications of this decision, it is causing emotional trauma to women and their families at an intensely vulnerable time. To date, it appears that the NMC has shown no concern for the physical and mental wellbeing of pregnant women who have booked with independent midwives.

At the very least, the NMC should, as Birthrights rightly insists, guarantee "that all women who are currently booked with independent midwives using the IMUK insurance scheme will be able to continue to access their services" and "that the midwives caring for them them will not face disciplinary action for fulfilling their midwifery role".

Aside from the horrifically rushed implementation, the decision itself just doesn't seem remotely reasonable.  NMC Chief Executive and Registrar Jackie Smith has responded with the claim that "The NMC absolutely supports a woman’s right to choose how she gives birth and who she has to support her through that birth. But we also have a responsibility to make sure that all women and their babies are provided with a sufficient level of protection should anything go wrong."

In other words: nice as a women's right to choose might be, what's really important is that she can sue for many bucketloads of money (not just a few bucketloads) if anything goes wrong.

Seriously?  That's your top priority?  This reveals deeply messed-up values.

(It's arguably wrong for the law to require indemnity insurance of independent midwives at all: The costs are of course passed on to clients, and it's not obvious what legitimate interest the state has in forcing expectant parents to pay for such cover.  I understand that in previous decades clients of independent midwives could just sign a waiver indicating that they wished to have midwifery care without such indemnity cover in place.  I would prefer to still have that option.  So I think the law is wrong.  But it's especially absurd for the NMC to not just enforce the minimal requirements of the law, but to zealously root out any midwifery care that might occur with large amounts of indemnity cover that just aren't large enough for their liking.  It's obscenely paternalistic, and deeply disrespectful of patient autonomy.)

Finally, there are procedural issues surrounding how unfairly the NMC has treated Independent Midwives throughout this whole process.  NMC has consistently refused to offer any guidance to IMUK regarding what level of cover they would approve of.  Indeed, the NMC's guidance booklet on their own website specifies on p.3 that "We are unable to advise you about the level of cover that you need. We consider that you are in the best position to determine, with your indemnity provider, what level of cover is appropriate for your practice."  IMUK did exactly that.  Now the NMC is punishing them (and continuing to refuse to explain how exactly IMUK could avoid such punishment).  Is that what the rule of law looks like in this country?

In short: The NMC has behaved with reckless disregard for the rights and interests of pregnant women, and their capricious oversight also threatens the livelihoods of independent midwives who have made every good faith effort to comply with their (unclear) demands.

If you share these concerns, please consider taking a minute to let the NMC know -- perhaps citing your support of the Birthrights letter [pdf] and reiterating its thoroughly reasonable demands.

Update: I see that the NMC claims that "Once the final decision was reached by the Registrar, the NMC had to act quickly in the interests of public safety." What a joke.  If you're going to take away a woman's midwife right before labour, on grounds of "public safety", it'd better be because the midwife has freaking Zika, not merely because we can't sue her for a large enough sum.


  1. The Nursing and Midwifery Council persistently claims that they are acting to ensure 'public safety'. This action has nothing to do with public safety. Public safety is ensured by midwifery education, training, the professional registration requirements and one-to-one midwifery care. The only thing insurance ensures is recompense for those families who are able to sue successfully for negligence and a lucrative income for lawyers and insurance companies.
    Beverley Lawrence Beech
    Hon Chair, Association for Improvements in the Maternity Services

    1. Indeed! I can't understand why they are doing this -- it is so obviously unreasonable and contrary to the interests of the pregnant women they are supposed to be protecting.

  2. How do insurance costs compare for doctors and midwives in other settings, and who pays for this? Why are independent midwives any different?

  3. The NMC has also disbanded the midwifery committee within its own organisation so the 40k midwives on its register have no meaningful representation. It really is starting feel like a witch hunt with midwifery as we know it 'regulated' out of existence.

  4. Add it to the bigger picture of the dismemberment of the NHS.
    At some point a corporate enterprise will come along and effectively be allowed by the government to take over all midwifery as a private money making venture, and they wouldn't want any competition from local independent operators.
    Midwives made redundant by the collapse of the NHS and independents going insolvent by this ruling will be left with no option but to work for this corporate body, but on less wage, worse conditions and no say in how the service is run, if they want to carry on being midwives.
    And expectant mothers will have to pay for the service, or be forced to have babies at home without trained supervision, just like in the 19th century and earlier. The profits of course will be run through an off-shore tax haven. This is the neo-liberal plan, regardless of what Hunt and May state, this will happen.

    The only counter (other than a prolonged national strike or civil uprising) to this is for midwives to band together and set up local midwifery services outside of the NHS, setting your own regulations, without telling government and other officials, and just carry on delivering babies, etc, but it will be home based in most cases, and with little monetary engagement other than what the local community can provide.

  5. There's a couple of important things the NMC have claimed: this only affects about 80 midwives; and that IMUK and their members knew about the problem for months but didn't tell their customers. Either those are lies - in which case it seems odd not to call them out on that specifically - or this starts to look like a cynical attempt to worry expectant mothers in order to score political points and/or deflect blame.

    1. Hi Jason,

      (1) Yes there are very few independent midwives in the UK. So only small numbers of people are affected. So what? The people who are affected (especially, the clients of independent midwives) are being harmed, not protected, by the NMC, and that makes their decision unethical.

      Indeed, the very fact that the NMC try to downplay the scope of their decision seems to implicitly concede that it harms rather than helps those affected. If they were really "protecting" us, it would be odd to add, "But it's only a very small number of people that we're hereby protecting".

      I would hope that the unaffected majority would sympathize with and support the minority of us who are affected, rather than dismissing us as unimportant merely because we are few in number.

      (2) The NMC did not reach a final decision until right before Christmas. While they had previously warned IMs that they were investigating IMUK's indemnity cover, and provisionally believed it to be inadequate, my understanding is that IMs believed (based on legal counsel and actuarial advice) that the NMC's provisional verdict was groundless and would not stand. Should they have warned their clients of the risk anyway? Plausibly so. But I don't especially blame them, given the subjective position they were in at the time.

      "this starts to look like a cynical attempt..."

      Are you referring to my blog post here? To clarify, I am upset because my family is personally affected: it is no longer clear whether our chosen midwife will be allowed to attend the upcoming birth of our first child.

  6. I love this piece. I feel precisely the same way. It seems the NMC have simply bullied IMS out of existence. Midwives need their own regulatory body away from nursing. They are completely different skills. Bev Turner

  7. You have said it well, Richard Chappell. How is it that the regulators can keep a straight face when they say they are protecting the public in this matter?
    I am a recently retired independent midwife in the State of Victoria, Australia, having practised without indemnity insurance, or with very little cover, for 20+ years. We have had the same blinkered charade of *public protection* happening for a long time here too. At present all health professionals are required to have professional indemnity insurance, and there is an exemption in place that applies to midwives who attend homebirth privately. And we sort of expect Australian regulators to meekly follow the example of the mother country.
    I think you are right to argue from the consumer perspective that it is in the public interest to have the option of a known/chosen midwife attend a woman in her own home, providing continuity of care.
    And if there are only 80 midwives, each of whom have a caseload of say 20-50 women, that's 1600-4,000 mother-baby pairs affected. They deserve access to appropriate care too.

  8. I had not realised that Independent midwives are under such threat. Surely the NMC should be able to help all Midwives in their role and that includes Independent Midwives. As an organisation they should take into account the shortage of midwives and the large number of midwives who leave the profession (yes - me)and actively encourage different models of working.

  9. In relation to the point above - as a current client of an Independent Midwife, I WAS told that the NMC were quibbling over the IMUK insurance provision when I booked. However the midwives had been assured by independent financial advisors that their indemnity provision WAS suitably capitalised, and had received legal advice that the NMC were acting outside of their remit to claim it was not. They therefore did not expect the NMC to pursue the matter, and certainly did not think they'd be as reckless as to ban them from practising with just three working day's notice. I can see why some midwives may have decided not to mention it (the legal advice was also not to disclose too much to avoid jeopardising the case), even though mine did.

    I am having my second baby and my chosen midwife also looked after me in my first pregnancy (when she had no insurance at all). I fully accepted the implications of this at the time, knowing that in the grand scheme of things, personalised, skilled, continuity of care was more important to me (and offered a greater reduction of immediate risk) than any financial protection offered by insurance. This was MY CHOICE, made as a professional risk and governance manager I would add. I was obviously very pleased when my midwife told me in this pregnancy that they did now have insurance, but given that she is amazing and saved my life in my first pregnancy, I would have gone with her again regardless. The NMC have now taken away my choice. I am nine weeks (potentially less) away from giving birth and still have NO idea where my birth will take place, or who will attend it. It is profoundly upsetting and stressful to me and my midwife, and I find it unspeakably patronising and reckless of the NMC to presume they are acting in my interests when they quite clearly are not.


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